A Science of Uncertainty
by spectrum mouse
Summary: A medical mystery of sorts. Carlisle Cullen works nights in the emergency room and is more than capable of handling anything from a cold to a cardiac arrest. But when a mysterious illness strikes the one closest to him, he must draw on all his training, experience, cunning, and empathy. But will it be enough?
1. Chapter 1 Viruses

Disclaimer: I don't own _Twilight_ , and am not making any money off this.

Author's note: Like Dr. Carlisle, I work in emergency medicine (and love it). Unlike Dr. Carlisle, I work in a prehospital environment, so I might have made an error or two when it comes to how emergency rooms work. Some of the patients are based on patients I've had over the years, but everything is HIPAA-compliant. I'm going to put a quick "glossary of terms" at the beginning of each chapter for the non-medical amongst you. If you have any questions leave them in the reviews and I'll answer them at the beginning of the next chapter. Also, don't tell my coworkers I wrote _Twilight_ fanfiction because I'll never hear the end of it.

Glossary:  
Thrush: refers to an oral candida overgrowth, basically a yeast infection in your mouth. Can happen as a result of antibiotics disturbing your internal microbes.  
Obecalp, nacl: "Placebo" spelled backwards and NaCl (sodium chloride, saline solution) respectively.  
Otoscope: The pointy scope with the light that the doc uses to check your ears, nose, and throat.

* * *

"Mrs. Beckins, I understand your concern, and I sympathize with your son's condition, but I can assure you that antibiotics will not help with a viral cold," I said to the frowning woman clutching her son on the bed in front of me. "The cold will run its course in a week or so, and he'll have a cough for up to four weeks, and then he'll be right as rain."

Mrs. Beckins's frown deepened. "Are you sure he has a cold?" she demanded. "You didn't even test for strep!"

"Your son doesn't have a sore throat," I explained. "Strep always presents with a sore throat. I can assure you, it's a cold." Plus, if he'd had strep, or any other bacterial malady, I would have smelled it the moment Jeremy Bekins started coughing on me.

"I still think he needs antibiotics," Mrs. Beckins insisted. "When I had a cold last year, I took some of my husband's leftover antibiotics and it was gone in a week. I don't want my Jeremy to be coughing up a lung for a month."

I had seen people cough up lungs. Or bits of them, anyway. Tuberculosis will do that to you. Jeremy wasn't coughing up anything except respiratory droplets teeming with more viruses, ones that I, fortunately, was immune to. I was not, however, immune to being annoyed that Shari Beckins had brought her child to the emergency room for a cold.

I tried a different tactic. "Mrs. Beckins, antibiotics are fairly serious drugs. You don't want your son to develop thrush or gastrointestinal problems just to get rid of a cold faster, do you?"

"Ha! They do get rid of a cold faster. I knew it!" Mrs. Beckins crowed. "The ones I took started with a V. It was something like victorsmicin. I want a script for that."

She probably meant vancomycin, one of the stronger antibiotics used for serious infections, which made it all the more worrisome that Mr. Beckins hadn't finished his prescription.

"I don't think that that would be helpful for a cold," I said.

"Well then what would?" she demanded.

"Rest, fluids, tylenol if the fever comes back. Most children's cough syrups and decongestants don't work, though some people have success with honey in children older than one."

"No, he needs antibiotics," she insisted.

A man of lesser morals would have longed for the days when it was more acceptable for physicians to prescribe "obecalp," or give shots of "nacl," and tell the patient that they would get better soon. It was unethical and a breach of trust, but I knew for a fact that it had made certain patient encounters a lot shorter than they otherwise would be.

"Well?" Mrs. Beckins pressed. "Are you going to write the script or not?"

"I'm afraid not," I said. "Your son's cold will go away on its own. Follow the instructions in the discharge paperwork, and you can follow up with your primary care provider if you still have concerns." I gave her my most charming smile.

She deepened her frown until I thought she might sprain a facial muscle. The charm doesn't work on everyone, apparently.

"Do I get a sticker?" Jeremy asked.

"I'll have the nurse bring you one when she gives your mom the paperwork," I told him. He deserved two, for putting up with that nightmare of a mother.

I quickly stepped into the hallway, Mrs. Beckins's squawks of "needs antibiotics" and "medical malpractice" fading behind me. I brought up my patient's chart on the computer and began rapidly, but not too rapidly, typing a note for the encounter.

"Shari in with one of her kids again?" Katie, one of the nurses, asked, clucking sympathetically.

I nodded. "The oldest, Jeremy. She wanted antibiotics for him, and I'm afraid I wasn't able to explain the situation to her liking."

"Don't feel bad," said Katie. "I don't think anything is ever to her liking. If you'd given her the antibiotics she'd have complained that they were fake antibiotics that didn't work or something. Did I tell you what she said when I tried to sell her on vaccines for the kids?"

I shook my head.

"She said that they were full of chemicals, and something about a conspiracy to give children autism. Like, what do you think's in antibiotics? And I thought we'd established by now that Wakefield is a quack and autism is genetic."

I smiled in amusement, and nodded. "Some people are reluctant to accept what's right in front of them, I suppose."

"You can say that again," Katie said, and headed for the coffee machine.

The only other patient waiting was a six-year-old male with a chief complaint of foreign object in nose. Dr. Snow, bless him, had been assigned the other two patients in the ER that night, a man with sudden-onset testicular swelling and a woman whose gangrenous foot ulcer I could smell from across the ER. I wished him luck, and headed for room five, with my hand resting on the small hot pack I kept in my coat pocket.

Inside, my patient was sitting on the bed, playing with a toy train and rubbing occasionally rubbing at his nose, no apparent distress. Looking tired and careworn, his mom sat in the chair next to him, absently stroking his back.

"I'm Dr. Cullen," I said, extending my freshly warmed hand. The boy's mother shook it and gave a weary smile, and I noticed no ring on her hand.

"Betsy Kemp. Nice to meet you." I inhaled slightly and caught a whiff of cheap makeup, store-brand laundry detergent, kids' snack food, instant coffee, and printer ink. Office worker, probably the lower end of the totem pole, trying to meet the equally brutal demands of work and motherhood, and doing it all alone. I felt for her, though I'd met people in far worse situations.

"And you must be Oscar," I said, turning to the boy.

He put down his train. "Yup. I put a tire up my nose."

"From his train," Betsy explained, gesturing at the toy. I looked down and noticed that one of the rubber washers around the wheels was missing.

"Well, let's see what we can do about that. I just have to ask your mother some questions." After confirming all the information in the chart, I put on gloves, more for Oscar Kemp's protection than my own. There were very few infections that preyed on my kind. "Why don't you lie down, Oscar. I'm going to shine a light up your nose."

"Okay," Oscar said. "Am I going to have to have an operation?"

"For this? No," I assured him, as he lay down and tilted his nose up. I took an otoscope off the wall and aimed the light up his left nostril. I could just barely see the edge of the rubber washer at the very back of the nasal cavity.

Katie had left me some hemostats in varying sizes on an instrument tray. I selected the smallest ones. "Oscar, I'm going to need you to stay very still for this part. It's not going to be very comfortable. I'm going to have to stick these tweezers—" I showed him the hemostats, "—up your nose to get the tire out. Can you hold still for that?"

"Uh-huh," Oscar said. Betsy leaned forward and gave his hand a reassuring squeeze.

I leaned over and, otoscope light still in my left hand, I slid the tweezers up Oscar's nose and snagged the rubber washer. Oscar whimpered as I pulled it out, but honored his promise to hold still. With a small smile, I held up the mucus-covered washer for him and Betsy to see.

"Wow!" Oscar declared. Before I could stop him, he grabbed the washer from between the hemostats, wiped it off on his shirt, and stuck it back on his toy train.

"Oscar, no, that's…" His mom abandoned the rebuke. She turned to me. "It's good for kids to be around some germs, right? For their immune systems?"

"That's a current theory, yes."

"We good to go?" She suddenly looked exhausted.

"I'm going to have a nurse print out your discharge paperwork, and then yes, you're good to go."

"Thank you," Betsy said, relief written all over her face. Then she winced. "Jesus. How much is this going to cost?"

Even after three hundred years, I still shuddered internally at what my father would have done to some who'd taken the Lord's name in vain like that.

I shook it off and said, "Don't worry about it. You've got insurance, and if the claim is denied the hospital has a very generous budget for forgiving medical debt. Most people only end up owing the copay." I didn't tell her that the budget came from a nonprofit I'd set up years ago, when I'd gotten tired of seeing people bankrupted by car accidents and cancer and childbirth complications. It was only proper. Even as far back as the Code of Hammurabi, it was understood that the rich should pay the doctor more because he cannot charge the poor.

"That's a relief. Thanks, for everything." Betsy put her arm around her son, who was happily spinning the wheels on his toy train. I threw away my gloves and went to see about the discharge paperwork.

My shift was almost over. Dr. Caldwell would be relieving me in about ten minutes. I hadn't saved any lives that night, but medicine, even in the age of science and evidence-based treatment, was rarely about saving lives. Every so often we could snatch someone from the waiting claws of the Grim Reaper, but mostly we were a refuge for the sick and the desperate.

And also for children with tires up their noses.

* * *

You review me; I review you.


	2. Chapter 2 Pain

Glossary:  
Toradol: a non-narcotic pain medication.  
Syncopal episode: medical-speak for fainting spell.  
A-fib: atrial fibrillation, an abnormal heart rhythm.  
Hospitalist: a doctor who works with patients admitted to the hospital.

* * *

I am no stranger to pain. The worst three days of my life were spent huddled among rotting potatoes, scared, confused, and trying not to scream too loudly as the venom worked its cold, fiery way through me. But I'm glad for the experience, because it's given me empathy for others' pain, something my profession sorely lacks. Patients in pain were often met with scorn and annoyance. After all, pain rarely brings out people's good manners, and it was sometimes impossible for us to tell legitimate pain patients from drug seekers, leading to a lot of frustration and tough decisions. But I know how it feels to be in pain, to be alone, to be afraid and confused and helpless, and I swore early on that I would never dismiss anyone else who faced the same situation.

It was something I bore in mind as I regarded the patient in room eight, a young woman in a Western Washington University sweatshirt who lay on her side, hugging her knees to her chest and fighting back tears. Twenty-one-year-old female, chief complaint of abdominal pain times two years, the chart said.

"I'm Dr. Cullen," I said, holding out my pre-warmed hand for her. She reached up and shook it weakly.

"I'm Annie."

"Can you tell me a bit about what brought you here today?" I was deliberately vague; I didn't want my questions to lead her answers, and I certainly didn't want to sound like I was judging her for coming to the ER at two in the morning for something that had been going on for two years.

"I know how this looks," she said, her voice rough with pain, "but my stomach is killing me. It's been killing me off and on since I was nineteen. These days, mostly on. And yes, I've seen my primary about it. And he said it was just period cramps, and I should take ibuprofen. So I saw a gynecologist, and she said that I was stressing too much and needed to relax. Third guy I went to thought I was a drug seeker, and that's when I gave up. I tried to ignore it, and relax, and take ibuprofen. And it's gotten worse. And I know it's probably not going to kill me right now, so it's not technically an emergency, but I have midterms in three days, and I can't take another second of this. I'm done."

I inhaled subtly. She smelled like sweat and instant noodles and rented textbooks and frustration and the acrid tang of menstrual blood. Also I was pretty sure I knew what she had. She was in for a long haul.

"I believe you," I said. "I don't think this is just cramps, or stress, and you were right to come in. I'm going to need to go over your history one more time, and do a few tests, and then we'll go from there. But first, I'm going to put in an order for some pain medication."

Annie looked at me with mild surprise. "Seriously?"

"Of course. You'll need a clear head to go over your medical history. Do you have any allergies?"

"Bactrim."

I made a note. "Taking any medication, including over-the-counter?"

"Ibuprofen."

I made another note, and went to put in the order for toradol. If that didn't work, I'd prescribe a low dose of Mobic or tramadol. Annie had been in pain long enough.

An hour later, Annie was sitting more or less comfortably on the toradol, describing the pain as "down to a dull roar." She seemed more relieved that I was taking her seriously than anything else.

And it was a good thing I had. As I suspected, the pelvic ultrasound showed multiple endometriomas adhering to her ovaries, fallopian tubes, and uterus. The pelvic exam I'd done had also been suspicious for uterine scarring, and although I'd done it as gently as possible, Annie had still gritted her teeth from start to finish. Her history was more or less what I'd suspected: heavy, painful cycles starting at age nineteen and getting steadily worse, until the pain was constant and then worsened during menstruation.

"It's highly suspicious for a condition called endometriosis," I explained to her. "It's caused by the uterine lining growing outside the uterus, which can cause all the symptoms you've been having. It takes surgery to diagnose it officially, though."

"Endometriosis," Annie whispered, turning the word over in her mouth. "En-do-me-tri-o-sis. So, how do we fix it? Do I have to have surgery or do I take meds, or what's the plan here?"

I sighed. This was the hard part. "There's no cure. Surgery and birth control can help some people, but a lot of it is just pain management. I'm afraid I'm a bit out of my depth, but I'm going to refer you to a specialist. I've known her for years; you'll be in good hands."

"No cure," Annie repeated. "Am I going to be in pain for the rest of my life?"

I shook my head. "I don't know. But I do know that you're not going to be in pain for the next few weeks. I'm writing you a prescription for two weeks' worth of toradol, and five doses of a narcotic called Mobic for the very bad days." I gave her a serious look. "Use them carefully, only when you really need them. And this is just a short-term prescription; you'll need to come up with a long-term plan with the Dr. Muir. Understand?"

Annie nodded. "Wow. This … this'll get me through midterms no problem. Wow. Endometriosis. Is it rare?"

"Not especially. It can be hard to get good numbers, but most common figure is ten per cent of women of childbearing age."

Her face darkened. "One in ten? If it's so common, then how come everyone else missed it? I went to three doctors, and two were gynecologists. How come it took a random ER doctor in the middle of the night to diagnose me?"

"I'm sorry," I said, on behalf of my profession. "I don't have those answers for you."

Annie signed her discharge paperwork, looked over the prescriptions and instructions and referral information, and walked out the front door, shuffling a bit but otherwise showing no signs of discomfort. I watched her leave, wondering if her pain would ever end, as mine had.

After she was gone, I stood for a moment, letting my mind go blank and simply absorbing the sensory information around me. The smell of floor cleaner and cavicide disinfectant and blood and pus and oxygen tubing and vomit. The sound of the lights overhead, the cars outside, the clacking of a keyboard, the hum of Dr. Snow on the phone with the hospitalist trying to get a patient admitted.

"Sixty-seven-year-old female, came in for a syncopal episode, in and out of a-fib for the past hour and a half," he murmured into the receiver.

"What do you expect me to do about it?" asked the hospitalist, the time-honored refrain of doctors to whom care is being transferred. The first time I'd heard that was in 1855.

Once I'd cleared my head, I logged into a computer and brought up some charts I had been meaning to catch up on. No other patients came in for the rest of the shift. Some paramedics called in to clear a refusal with us, and I happily took the call and gave them my name and license number for their report. Then Dr. Caldwell arrived, seven o'clock on the spot as usual, and I was free to leave.

Esme was waiting for me when I got home. The rare morning sunlight shone through the windows and made her skin glitter. She saw my taut expression and touched a pale hand to my face.

"Hard day?" she asked, pulling me down onto the couch next to her.

"Not really. I just had one of those patients that comes to me after the healthcare system fails them."

"You set it right, though, didn't you?"

Her faith in me was touching. "I did what I could," I said, lacing my fingers with hers, our old I-love-you from back in the day. "It was a quiet night, overall. And how are you?"

"Well, I made a few cabinets, just small ones. Oh, and it's going to be sunny off and on for the next week, so the kids are planning a hunting trip. I've written them a school excuse."

I kissed her forehead. "That will be good for them. What are you going to do with the cabinets?"

"You know, I'm not sure." She rubbed my shoulders. "Maybe give them to a thrift store. I didn't really have a use in mind when I made them; I just wanted to do something with wood and screws and it's been a while since I've worked on a house. I haven't really been doing much lately."

"Do you want to go hiking today, or maybe hunt?" I suggested.

She shook her head. "I don't really feel up for it."

That was strange. It would be a completely innocent thing for a human to say, but Esme was supposed to be immune to the ravages of fatigue and malaise. She'd never not felt up to something in the time I'd known her. I tried to put it out of my mind as she pulled me into her lap and ran her fingers through my hair. If she didn't feel like going out, we'd have a nice day on the couch, just the two of us.

With some effort, I shut off the medical part of my brain and concentrated on the here, the now, the seconds of the eternity that I had to spend with the woman I loved.

* * *

You review me; I review you.


	3. Chapter 3 Trauma

Glossary:  
Decubitus ulcer: medical name for bedsores, wounds that develop when a patient is left in the same position for long periods of time.  
Cincinnati (stroke scale): the face-arms-speech-time test used to determine if someone is having a stroke.  
Satting/sats: refers to the amount of oxygen in the blood. Ideally above 94% on room air.  
EMTALA: The Emergency Medical Treatment and Labor Act. Basically says that emergency rooms aren't allowed to turn people away.  
Edema: medical name for swelling  
ETOH: Alcohol, also refers to someone who has consumed it excessively.

* * *

"Hey, that's all we know," Elias said, as I signed his run report under transfer of care. He gestured at a face sheet and physician's notes that were left on the desk in room two. "The family didn't give a history when they dropped her off, and the nurse tried to call them back but the number they gave had been disconnected."

I thanked Elias, and he and his partner, a newcomer still wearing the stricken face of someone in her first month of emergency medicine, headed for the EMS room to finish their report and restock their ambulance. I turned and watched Katie taking vitals on my patient, a seventy-four-year-old woman whose family had seemingly abandoned her at an assisted living facility. She was confused, could not care for herself, and by the smell of her had an active shingles rash somewhere on her body. The facility had sent her here because they needed her medically evaluated, including tests to determine whether her confusion was caused by dementia, a past stroke, or something else entirely.

At least the patient seemed happy enough. She was trying to talk to Katie about the weather, and I noted that she was unable to follow a coherent train of thought, forgetting that she'd already said something and repeating herself. Probably I couldn't diagnose her in the ER. She'd need to be admitted, which was going to mean a long argument with the admitting hospitalist, since this was far from an emergent case, and then probably many more arguments with the various assisted living facilities in the area to try and find a place for her.

My vampirism was a curse; that much I knew. But I couldn't help but feel blessed that I would never end up like this woman, no matter how much time passed. I would never be warehoused in a nursing home, neglected by staff while decubitus ulcers ate through my skin. And my family would never abandon me, nor I them.

I put my orders into the computer and sat down to do some charting. Before I could begin, I heard the double doors to the ambulance bay open and Elias and his partner rolled in with a familiar face looking up from the stretcher. I looked away and tried to complete as much charting as I could before I was called to assist, which I inevitably would be. I'd made the mistake of learning Spanish several centuries ago, and I was the only person on the night shift with the fluency to take someone's medical history.

Half a page of notes later, Malik, the nurse, called my name. I stood and reluctantly made my way to room one, where Elias and his partner were still in the process of coaxing their patient off the stretcher and onto the bed.

"If you can't scoot, we can move you on the sheet," the partner was saying, with the exaggerated clarity people used when talking to non-native English speakers.

"Naw, he can scoot," Elias insisted. "C'mon, Pedro, vamanos." He motioned for Pedro to slide himself from the stretcher to the bed.

"Es muy dificil," Pedro protested, slurring badly. He stank of alcohol and human body odor.

"You weren't gone long," I commented to Elias, moving my shoulders to hide that I'd stopped breathing.

"Caught a call right out the door," he said. "This guy was outside the liquor store down the street."

Pedro, with a mighty groan, finally managed to haul his bulky frame onto the bed. Elias deftly moved the stretcher away and raised the bed rail. He headed for the EMS room, guiding the stretcher one-handed with practiced ease. His partner started to follow, but Malik stopped her with a glare.

"Report?" he asked, eyebrow raised.

"Oh. Yes." She stopped and stood up straighter. "Um, male, fifties, bystander found him lying on the grass outside a liquor store. Says he has been drinking but only two beers."

Malik snickered at this part. "That's what they all say."

"Negative cincinnati, glucose of 129, satting at 97, pulse of 88, resping at 14, b/p 144/78, lungs are clear, pupils are responsive, normal skin parameters," Elias's partner recited, sounding a little short of breath. "Um, don't know his history or allergies or meds because my Spanish kind of sucks. But I think he was, um, trying to flirt with me on the way here, so …" Her cheeks started turning the color of fresh tomatoes.

"Relax," I told her. "You did very well. What's your name?"

"Myra," she said, still looking mortified. "Do you need anything else?"

"No, that will be all." Myra scurried out of the room like something was chasing her. It was definitely her first week on the job.

"No te vayas! Tu es muy bonita," Pedro protested as she left.

"Well, Pedro," I said, turning to face him, "como estas hoy?"

"Tu es muy bonito tambien, Senor Doctor," he assured me.

After much coaxing, Pedro then proceeded to tell me how he was a little drunk right now, but had only imbibed two beers. ("Dos cervezas, es verdad!"). He'd been to the hospital many times before, and I was able to look up his medical records to find his history and allergies. This was the latest in a series of visits that began with him being picked up by EMS, and ended with him discharged once he was sober. I'd tried to get him a bed at an inpatient rehab facility a few times, but had come to realize that he wasn't an alcoholic, just a dedicated recreational drinker with exceptionally poor judgment and even worse hygiene. And there was nothing I could do about it except give him the standard alcoholic workup because EMTALA required it. It angered me, in my weaker moments.

Now was not one of those moments. Despite my earlier resolution to stop worrying about it, I couldn't stop thinking of Esme. I wondered if there'd been signs of illness that I'd missed before last night. She'd never been as fast a runner or as vicious a hunter I was, which was odd, since male and female vampires of didn't differ physiologically. My best theory was that it was because I'd turned her so soon after she'd given birth, before her body had been able to recover. Since the human body was "frozen" at the time of transformation, she might have been frozen in that weakened state. But it was only a theory. Not much was known about vampire physiology. We healed from any injury within a day, and so few pathogens affected us, so there was little use for vampire doctors. Most of the literature about us was theory and speculation, if not outright legend.

A few vampires who worked in the scientific fields had done some studying. A colleague at Cornell had quietly figured out how much venom it took to transform someone—roughly two and a half milliliters, any less would simply scar and cause pain, but not a transformation. She was very interested in the transformation process itself, and most of the hard science on humans transforming into vampires came from her, though I tried hard not to think about her methods.

Another researcher I knew, this one based in England, was more interested in special abilities. She agreed with my theory that a human's talents can become amplified, like Jasper's empathy and Edward's knack for reading people. There was the question, too, of what counted as an ability. Did everyone have some kind of ability, with some more subtle than others? For instance, I managed to work around human blood every day without much temptation. I'd always attributed it to years of practice, but Dr. Sutcliffe wondered if I had my own gift.

But no one had really studied disease and illness in vampires, because the consensus was that it simply didn't exist. There were a couple of mildly toxic substances that would give us a rash, and we could get intestinal blockages from eating solid foods, but the substances were rare, and human food was about as appealing as steamed compost after someone turned.

If I got stumped treating a human patient, there was always UpToDate. The Mayo Clinic website if I was desperate, which was not often. If something was wrong with Esme, I didn't have a lot of resources I could pull from.

I finished the orders for Pedro's workup and went to check on the old lady in two. She was resting comfortably. On a lark, I added one more test to the orders, just in case. I was the first to admit that it was a zebra hunt, but there was a smell about her that I couldn't quite place, and it never hurt to check.

Katie came up behind me, so quietly that I barely heard her. She was snapping on a pair of gloves, the way she did when we had a trauma incoming. We were only a level two trauma center, so we never got the truly gruesome cases, but the broken bones and concussions and minor car accidents still got Katie a little excited.

"What is it this time?" I asked, following her into room nine, the larger room we used for traumas and arrests.

"Probable broken arm, self-inflicted. EMS picked him up at the police lockup. I just want to use the big room in case he's under guard." She began checking all the supplies in the room, making sure the monitor had batteries and we had all the proper supplies.

"This should be interesting," I murmured. Patients who came from a police facility always were.

I smelled the diesel and heard the backup alarm as the ambulance slid into its parking space. Through the antiseptic odors of the ER came the piercing scent of human blood, and the fresh plastic smell of splint boards. A second later, Elias and Myra rolled in again, dragging their stretcher between them. A mustachioed police officer, the chief if I wasn't mistaken, walked beside the stretcher, keeping an eye on the handcuffed patient. They stopped by registration, where the clerk took a few notes and pointed them to us.

Their patient was a middle-aged man with a dark suntan who smelled similar to Pedro. He had a hematoma and some swelling on his left hand, and his left arm was encased in splint boards and bandages and tape, no doubt Myra's doing. The young were always so overzealous with their splinting. His other hand was cuffed to the stretcher rail.

"Man, why does my arm hurt so much?" he asked, shifting uncomfortably and pulling at his cuffs.

"Because you punched a locked door very hard," Myra explained, her tone making it evident that this was not the first time they'd had this exchange. She turned to me and said, "Forty-two-year-old male, cops picked him up for ETOH, punched the door of his cell very hard. He is unable to move his fingers, and his hand and arm are very swollen, but no abnormal movement or crepitus. Um, splinted, as you can see. He's alert and oriented to person and time, not combative but confused and seems to have some memory loss. No meds, history of hypertension, no allergies. Lungs are clear, pupils responsive, normal skin parameters, blood pressure 156/94, pulse of 70, resping at 18, satting at 99, with a glucose of 88. Um, anything else?"

"Thank you, Myra," I said, as I helped her and Elias slide their patient over onto the hospital bed. The police chief quickly refastened the handcuff around the bedrail. I turned to him and asked, "Is this gentleman under arrest?"

He nodded. "I was going to let him sober up in the lockup, but we ran his name and it turns out he's got some warrants over in Tacoma. They're sending a car, and they'll take custody of him when he's discharged. Me or one of the boys will wait with him until then."

"Pull up a chair," I invited, as Katie wrapped a blood pressure cuff around the patient's good arm and clipped a pulse oximeter to his finger. I got a pair of scissors and started cutting away Myra's splinting work so that I could see the arm for myself. The patient winced and pulled away.

"Man, why does my arm hurt so bad?" he asked. "Why's it hurt?"

"Do you remember punching a door?" I asked.

"Door?" This was news to him. I sniffed at his head discreetly and was rewarded with the sickly sweet smell of brain edema. I gave his head a cursory exam and found a slight dark spot on the left side, barely a bruise and hidden by his shaggy hair and deep tan, easily missed in the field.

"Chief, did this man fall at any point, or sustain any head trauma?"

The chief shook his head. "Not since he's been in our custody. Before then, I can't say."

I put in an order for a head CT. Head trauma plus the blood-thinning properties of alcohol were rarely a good combination.

"You thinking concussion?" Katie asked me, squinting at the almost-bruise on the patient's head.

"It's possible." I took out a penlight and checked his pupils. They were responsive, but a bit sluggish, something Myra could easily have missed with her inexperience. I showed Katie, who nodded worriedly. Without even asking, she picked the phone up off the wall and called radiology.

"Is he going to have to stay here long?" the chief asked, leaning forward in his chair.

"It depends on the results of the CT, but it's possible," I said. "Will you need to call someone to relieve you?"

He nodded. "I've got places to be tomorrow. A friend of mine on the reservation is going to sell me his truck, so there's that to take care of, and if I'm being honest with you, it's going to be prime fishing weather."

"Is that so." I hadn't caught a fish in a few centuries. They had very little blood, and were incredibly hard to catch, plus most of them had a briny taste that I'd never gotten used to. My daughter Alice loved them, though.

"Oh, yes. The trout will be jumping," he assured me.

Malik arrived with the portable x-ray, and we took a few pictures of our patient's arm. I glanced at the films and saw nothing except a fractured metacarpal and a greenstick fracture of the distal radius, consistent with the stated mechanism of injury. Not that I had any doubts. Unlike some cities I'd worked in, the police in Forks didn't seem terribly inclined to abuse people in their custody. As Katie finished getting him a splint and sling, a woman from transport arrived to take him up to CT.

As I watched them go, I felt the familiar sense of satisfaction that my unique nature had been instrumental in getting the man the care he needed. There'd been barely any sign of head trauma, and I would otherwise have been inclined to cast his arm and let him sleep it off until Tacoma's police arrived. I wondered if my father was wrong, and vampires weren't inherently good or evil. We were the sum of the choices we'd made and the effect we had on the world. And if that was true, perhaps I would find favor in the eyes of God after all. I hoped so, at least.

My test results had come back for the old lady in two. As I'd suspected, her altered mentation was at least partly due to tertiary syphilis. An untreated infection, probably from decades ago, had laid dormant inside her until one day, it began to eat away at her brain. The damage was irreversible, but at least I could stop it from getting any worse. I wrote the order to start her on a course of antibiotics.

After my replacement arrived, I gave the handoff report and headed home, eager to see how Esme was faring. I found her on the sofa in our room, an arm over her eyes, looking weak and limp. If she were human, I would have thought her asleep.

"What's wrong, my love?" I asked, touching her shoulder.

She sat up slowly and winced. "I don't know. When I was human I used to get the most awful migraines. Did I ever tell you that?"

"It's odd for you to be having them now," I said, perturbed. I sat down next to her. "The transformation should have gotten rid of any chronic pain disorders."

She shrugged and pinched the bridge of her nose. "Well, not in me, it seems. It's not as bad as it was before, but it's still a headache and it's worse when I move."

"Interesting," I murmured, putting an arm around her slender shoulders. I hadn't felt pain from an internal cause since I turned. I'd never heard of anyone else who had, either. We could feel pain from trauma, but our own bodies never betrayed.

"It'd explain why I've been off my game lately," she murmured, leaning her aching head against my chest. "I was trying to hunt this morning, just deer, and one got away from me. I—I just wasn't fast enough."

I lifted her chin and assessed the dark spots beneath her eyes. They were a deep purple, and her irises were dark.

"How long since you've had anything to drink, love?"

She shrugged. "A week, maybe ten days. But I'm not especially thirsty. I'll try to hunt again tomorrow; I'm sure it's nothing."

I held her close to me, felt her warmth, her breathing synchronized with mine. I'd loved Esme for nearly a hundred years, and they'd been the best of my life. She'd spent those years protecting me as much as she had her children, because Esme Cullen took care of her own. Now I only hoped I would be able to do the same for her.

* * *

You review me; I review you. Happy holidays!


	4. Chapter 4 Arrest

**A brief note before we begin** : the first part of this chapter features content that more sensitive readers may find disturbing. Discretion is advised.

Glossary:  
Basic (life support): In the context of prehospital care, BLS refers to providers with an EMT-Basic certification and ambulances equipped with automated defibrillators, basic airway supplies, splints bandages, oxygen, a few drugs, and suctioning supplies. BLS ambulances in most systems do not have cardiac monitors, IV supplies, intubation kits, and more serious drugs like nitroglycerin and epinephrine. Some systems only have advanced life support (ALS) ambulances running 911 calls, and others, like my own, have both. I don't know what protocols Clallam County EMS uses, so I'm just writing with the protocols that I use. Apologies for the creative liberties.  
Apneic: not breathing  
Angiocath: a needle with a catheter used to start an IV.

* * *

My mind was not on work the next evening. I gave every patient the usual thoroughness and attention, but my thoughts were elsewhere. I'd written emails to a few scientists I knew who studied vampires, and was still waiting to hear back. For the short term, I'd discreetly asked Alice to bring some extra blood home next time she hunted, in case Esme was still unable to hunt.

But this was my last night working for the rest of the week, and I hadn't volunteered to take anyone else's shift. Hopefully the rest of the shift would pass quickly and quietly, and I could spend the next few days tending to my wife.

No sooner had the thought occurred to me than the telemetry phone rang. I looked around, but Katie and Malik and the other nurses were busy. I sat down with a pen and hit answer.

"This is Clallam Unit 303 coming in basic with a full arrest," came Myra's shaking voice over the line. In the background were the sounds of chest compressions and the whoosh-whoosh of ventilations with a bag-valve mask. "Five minutes out. Ready to copy?"

"Go ahead," I said, pen poised above a radio form.

"Twenty-two-year-old male, found unconscious on the living room floor by his mother. Sh-she says he was breathing when she found him but when we got there he was pulseless and apneic." There was a pause as someone shouted at her. She resumed: "Three rhythm checks, no shock advised. We, uh, have airway access with a King tube and are ventilating on a hundred per cent oh-two. Patient has no known medical history, is not taking any medications, no known allergies. Oh, um, glucose of 80. We-we'll be there in five."

"Okay, see you in five," I said, and hung up the phone. I looked up and saw that Katie, Malik, the two techs on the code team that day had gathered around me to listen to Myra's report.

"Room nine," I said, my voice calm but commanding. "Have a cardiac monitor and IV supplies ready. They're basic, so they won't have established IV access in the field. Tia, take over compressions. Malik, you're IV and drugs. Katie, airway, and Artie, scribe. Any questions?"

Everyone shook their heads. We made our preparations and stood around the waiting bed, eyes fixed on the ambulance bay door. A solemn hush fell over the ER, a silence interrupted only by the accelerated beating of human hearts.

And then the silence was over, shattered by the squeal of the ambulance bay doors. Myra rode the rails of the stretcher, doing compressions one-handed and holding on with the other. Elias walked at the head, guiding the stretcher with one hand and squeezing the bag-valve mask every six seconds. At the foot was a firefighter, his portable radio hitting the stretcher frame as he walked. Between them a young man, barely an adult, lay on a bright orange backboard, arms flopping at his sides with the force of Myra's compressions.

Elias and the firefighter steered the stretcher alongside the bed, and a storm of hands went to work unstrapping the patient. Katie took over bagging and Elias stepped back. Myra, her face a blank wall, hair plastered to her face with sweat, kept doing compressions until Elias pulled her away. We lifted the patient over to the bed on the backboard, with me careful not to bear too much of the weight, and Tia took over the compressions a half-second later, pushing fast and hard. Malik immediately uncapped an angiocath and tried for a vein on the patient's left arm. I unhooked the defibrillator pads from the automated defibrillator and plugged them into the cardiac monitor.

"Twenty-two-year-old male, found unconscious and unresponsive by his mom about five minutes before we got there. We found him pulseless and apneic with an unknown down time," Elias began. "We did two more rhythm checks en route with no shock advised, airway access with a King tube and getting good chest rise. Mom rode with us; she's in the waiting room. She says he has no medical history, no drug abuse. We worked him for about twenty minutes before the fire department got here and we could go."

"You couldn't get an ALS crew to help?" I asked.

He shook his head. "I called for one, but we only have two ALS rigs up today and they're both on the other side of the responding area, so we just grabbed a firefighter to help with compressions and got here as fast as we could."

"You did well," I assured him, seeing the remorse on his face. Then, to my team, "Let's do a rhythm check."

We stopped compressions and swiveled our heads to look at the monitor. The rhythm was asystole, no electrical activity in the heart.

"I'm in," Malik announced, tossing his used angiocath in the sharps box.

"Push five of epi, then run fluids wide open," I instructed.

"Pushing epi—epi's in," he said. Artie's fingers flew over the keyboard as he recorded everything we did. A phlebotomy tech came in and quickly drew blood for an electrolyte panel and an arterial blood gas.

The EMTs hurried their stretcher out of the room to make room for us. Tia grew fatigued after a couple of minutes of compressions, so I switched out with her. Malik pushed another epinephrine, then lidocaine. Another rhythm check, still asystole. I paused so that Katie could intubate. The tube went in on the first try, and Tia confirmed the placement with her stethoscope. I resumed compressions, keeping an eye on the clock. The longest I'd ever seen anyone do chest compressions without getting tired was twenty-one minutes, so I always asked someone to rotate in for me after fifteen, even though I could easily go on indefinitely.

The lab called back with the results; all the tests were normal. This was bad; electrolyte imbalances and acid/base imbalance were fairly simple to correct. There was nothing we could do except continue our grim task.

We worked for almost half an hour in the fevered silence of a cardiac arrest, until finally, after thirteen more rhythm checks showing asystole, and no gas exchange on the CO2 detector, I told everyone to stop what they were doing. They stepped back, deflated. Solemnly, I called time of death. The cardiac monitor emitted a steady tone until someone silenced it. We stripped off our sweaty gloves, dejectedly threw them at the nearest trash can. The patient, younger than I'd been when I died, lay amid a jungle of wires and tubes with the flaccid stillness of death.

Katie stayed behind, helped me disconnect him from the IV tubing and cardiac monitor, and roll him off the backboard. The man's mother was in the waiting room, and one of us was going to have to tell her that her son was dead.

"I'll do the notification," said Katie, handing me the backboard. "You give this back to the crew if they haven't left."

She'd given me the easy job, and I was grateful. With the plastic board under one arm, I peeked my head inside the EMS room. Elias wasn't there, but Myra sat in one of the plastic chairs, shoulders shaking. When she heard me, she turned and looked up with shell-shocked eyes.

"First arrest?" I asked, leaning the backboard against the wall.

She nodded and wiped her eyes on her sleeve.

"The first one is the hardest," I told her.

She nodded again and said, "You called it, didn't you? He's dead?"

"Yes."

"It just doesn't seem fair. We were the same age, born the same month and everything. What kills a healthy young guy like that?"

"It could have been a number of things," I said. "Congenital heart defect that went undetected, or a malformed blood vessel in his brain that burst."

"Oh." She looked around the room, avoiding my gaze.

"You should tell someone about this call," I said. "Tell them what happened, and tell them how it made you feel. You'll feel better afterwards."

"Do you know this from experience?" she asked, scowling a little at the platitude.

"Yes. I'm older than I look, you know."

"It just doesn't seem fair is all," she murmured, and then became very fixated on a loose thread on her windbreaker.

"How many hours left in your shift?" I asked her.

"About forty-five minutes. We're probably going to get returned after this, provided our replacement shows up."

"Good." I wouldn't want someone in her condition running calls. "Go home, eat something, and gets some rest, okay?"

"I will. Thanks, Dr. Cullen," Myra said. "For, you know, understanding. Eli's nice and all, but this stuff's never bothered him, and he thinks I just need to get over it, whatever that means."

I gave a wry chuckle. "Get over it just means stop showing emotions that make other people uncomfortable. Myra, under no circumstances are you ever to "get over" this or anything else."

"That's funny. Also true. Well, we've been tied up here long enough. I'd better go." She stood up and awkwardly picked up the backboard with one arm. "Thanks for everything."

She walked out the door, and a minute later I heard the ambulance drive away. On the other side of the building, a piercing wail erupted from the waiting room, loud enough that a human could have heard it. It was the sound you hear when someone loses a child.

The rest of the night was quiet, as if God sought to make up for the evening's tragedy. There was a twisted ankle, some abdominal pain, and a man from the police lockup who claimed he'd been vomiting blood, despite no bloody vomit being found anywhere near him. I saw Elias with another partner; he'd stayed for a double shift. Myra, he told me, had gone home.

"I thought she was one of the good ones, but I guess some people can't handle the pressure," he said, as I signed his report.

"Give her time," I advised. "She'll learn to deal with it. I did."

When my replacement finally arrived, I drove home through the early morning light at what for a human would be a truly unsafe speed. Even with the events of the evening, I hadn't forgotten Esme's condition. At the red light before the gas station, I checked my email on my phone. Anna Camp, a vampire physiologist in Sydney, had sent me a couple of pages of her notes, plus a link to a paper she thought might be relevant, and Beatrice Sutcliffe from Oxford had given me as much as she knew. I didn't have time to peruse in depth before the light turned green and I shot off into the night.

Alice had left an entire gallon of moose blood in the fridge, more than I'd asked for. I sniffed it, and my mouth watered with venom. It was blander than predator blood, but it was rich in iron and proteins, which was the important part.

Esme hadn't had anything to drink in almost two weeks, and while vampires could survive long periods without food, we started to weaken after three weeks to a month. After that came cognitive symptoms, difficulty concentrating and the occasional hallucination. Almost a year of starvation was needed to send a vampire into a desiccated, semi-comatose state, where we could exist indefinitely. I knew because I'd lived it, the early stages at least. The later stages, the coma, I'd watched the Volturi inflict on a rogue vampire. It had not been a pretty sight. I shuddered at the thought of Esme experiencing even a little of it. Her human life had been harsh and short, so I always tried my best to keep her second life as comfortable as possible.

I poured some of the blood into a cup, careful not to spill any, and zipped up the staircase to the room Esme and I shared.

She was lying on the couch where I'd left her, chest rising and falling sporadically, sunken spots under her eyes bruise-purple against a waxen face. She barely stirred when I came into the room.

"Esme," I said. "Esme? How do you feel?"

"All right," she murmured. "Weak. The pain's gone, though."

"Well, I suppose that's something. Can you sit up? Alice brought blood from her last hunt."

She needed my help, but she was able to raise herself into a sitting position. I held out the cup of blood. She sniffed at it, then turned her head away, disinterested. I sat down next to her, biting my lip in worry. Vampires never refused blood. Even at the depths of his depression, Jasper had never stopped hunting. Our defining trait was our need for blood, and starvation only made the thirst burn stronger.

"Darling, you're becoming ill," I protested. "You need to drink something. Just a few sips, please?"

"I don't want any blood, Carlisle," she said, resting her head against my chest. "I'm just tired. I wish I could sleep. You know, that's something we never got to do, sleep next to each other. It figures—sleep is such a vulnerable state, and by the time I finally meet someone I can be vulnerable with, I've lost the ability to sleep."

"We can do other things together," I murmured, wrapping my free arm around her shoulders. "We can climb to the top of the tallest mountain and I'll hold you in my arms while the snow falls all around us."

She smiled into my sweater. "I'd like that. Or we could fill our lungs with water and sink to the bottom of a coral reef, and I'd hold your hand while we went to find a moray eel."

I shuddered; I hate eels and she knew it. "Maybe we could just lie in the sand and watch the sunlight on the water above," I suggested. "But first, you need to be strong enough." I lifted her chin and held the cup to her lips. She tried to pull away, but I tilted the glass up and managed to get a sip or two into her. She swallowed, looking disgusted.

"I said I wasn't thirsty," she protested. "Carlisle!"

"You need nutrients," I said. "You need iron, and you need proteins and platelets, and you're dehydrated. I'd feed you straight plasma if I could."

"I'm fine like this," she protested. "Besides, it tastes like rotten metal. Alice must have left it in the fridge too long."

I took a quick sip myself. It tasted like moose blood, colder than I was used to, but still palatable. Good, even. I sighed and put it down on the coffee table.

My laptop was on the table where I'd left it charging. I shifted us so that Esme was laid out across my lap, and I could reach over her and check the notes that Anna and Beatrice had sent me. I hoped her illness would turn out to be something simple, a bad reaction to a new type of wood varnish she'd been using, or something like that.

Anna's notes were rudimentary, the basics of how vampire physiology worked. I'd known most of it, but not all. The venom used to incapacitate a victim is also our means of reproduction. It rewrites the human DNA on a cellular level, causing a cascade effect of changes, not all of which were fully understood. The end result is a being made of a material that more resembled industrial ceramics than flesh and blood. We have no circulatory system, just a network of pores that diffuses nutrients throughout the body, much like mosses and fungi. Our bodies are largely self-repairing; that part isn't understood properly, but Anna found that healing times vary based on how recently a vampire had fed, and on what kind of blood. Human blood, of course, is better, but reptile is a close second.

Blood is digested by the stomach and small intestine, which are much the same as in humans. The large intestine and excretory system are no longer necessary; a vampire's digestive tract uses every part of the food. Because of this increased efficiency, and the additional time it takes to get nutrients out to the cells, it is not necessary for us to eat as often as humans. Our body temperature is usually around the same as the ambient temperature, usually a few degrees cooler since we don't hold heat very well. Variations in temperature can speed up or slow down metabolism, which is why we are less thirsty in winter.

The link at the bottom lead to a more detailed report about vampire neurology. Anna had apparently found an excuse to run herself through some fairly extensive neural imaging tests, and made a few discoveries. First, predictably, the vampire's brain is just as efficient as the body. It is constantly "sleeping" small parts of itself, which is why vampires don't need to sleep at night. We also have more activity in the sensory cortices, unsurprising given our heightened senses. The brainstem, responsible for basic functions like heart rate and temperature in a human, has about a quarter of the activity compared to a human. The hypothalamus, on the other hand, lit up on the scan like a Christmas tree, even moreso after Anna had waved a swab dipped in human blood under her nose. That, she theorized, was the source of the appetite, the lust for human blood.

Could be targeted, she's written at the bottom of the page, to curb appetites in newborns. Further research necessary. I stroked the back of Esme's head and wondered if the hypothalamus was the root of her illness. Perhaps a new type of disease had evolved that could attack vampires' brains? There were more of us that there had ever been before, and bacteria evolved quickly. Perhaps it was attacking her hypothalamus like tertiary syphilis would attack a human's brain.

Dr. Sutcliffe had basically emailed me her entire hard drive. She'd met Esme once, while we were was at a conference in England, and they might have become close if not for Dr. Sutcliffe's frequent indulgence in human blood. But there remained a fondness, and Beatrice had dropped everything once she heard that Esme was ill. I began sifting through years of notes and write-ups, mostly about giftedness in vampires, and the traits that carry over after the transformation.

The only thing that caught my eye was a few notes about some psychological tests that Beatrice had run on Esme looking for hidden abilities. The only thing she'd unearthed was what Esme called maternal instinct, and Beatrice called long-range empathic abilities. Esme, apparently, maintained a sort of connection between herself and her family, and could tell if something was wrong with me or any of the children, even over great distances. There had been, of course, no ethical way to test this ability. I smiled to myself, recalling instances when Esme had instinctively known when one of the children was upset or worried or needed our help. I'd never paid it much mind before. Why hadn't Esme told me that she was slightly gifted? Probably because she was a modest woman, and had thought it vain and presumptuous to put herself in the same class as Edward and Alice and Jasper.

I looked down at her, lying across my lap, unmoving, eyes open but not seeing. Deep in me, I nursed a gnawing worry that I'd never figure this out. One thought in particular was especially disturbing, and I'd tried my best not to entertain it until now. Whatever this affliction was, could Esme die of it?

* * *

Thank you to catharticone and everyone else who reviewed. You keep me going. (Also check out catharticone for the treasure trove of Twilight fics. They are an amazing author).


	5. Chapter 5 Blood

**Glossary:**  
Failure to thrive: most commonly refers to children who don't gain weight or grow as expected. Can also refer to weight loss and malnutrition in adults, usually the elderly or chronically ill.  
Parenteral nutrition: giving someone nutrients through an IV line.  
Nasogastric tube: a tube that goes up the nose, down the throat, and into the stomach, and can be used to administer medication such as activated charcoal, provide nutrition to someone unable to take food by mouth, or to empty the stomach.

 **Note:** while it does not deal directly with the topic, this chapter may be triggering to those who've had eating disorders.

* * *

"How is she?"

It was Alice, my youngest daughter. Her faelike face was creased with worry.

"The same," I reported. It had been twelve hours since Esme had moved from her position lying on the couch. "Where are the boys?"

"Still hunting," she reported. "And Rose is shopping in Tacoma. They won't be back until tomorrow. But they know something's wrong. Emmett was there when she missed that deer."

I nodded gravely, and looked down at my wife's pale, sunken eyes, her lips stained with dried blood from my earlier attempt to feed her. She breathed a few times an hour, a shaky inhalation through the nose. It was a ghoulish spectacle. Alice looked too, with big sad eyes.

"We need to make her drink." My daughter said it before I could.

"Yes. She said your moose blood tasted off, but I couldn't taste anything wrong with it."

"It could be the refrigeration. Maybe if I brought her a small animal or something, live, she could drink it fresh. Maybe she'd like that."

I shook my head; even if she were healthy, she wouldn't like that. Esme was a merciful huntress; she did not taunt her prey, or fight it like the boys sometimes did. She went for the clean kill, and the animal was dead before it even had time to be afraid. She wouldn't approve of us holding some poor raccoon or muskrat captive for hours before we killed it. She would probably just take the poor creature outside and let it go with an apology.

"You're right," Alice said with a sigh. "Maybe give the moose blood another try?"

"We could try."

While Alice fetched the blood from the fridge, I helped Esme sit up. Alice brought a cup with a straw this time, and she offered it with a hopeful smile.

"It's very sweet of you, but I'm not thirsty right now," Esme murmured. "Please, I don't want any blood."

"Momma, no, you need to drink," Alice begged. "You're just going to get sicker and sicker—how is your throat not on fire?"

"Alice," I whispered, placing a hand on my daughter's shoulder. She moved back and set the cup down on the desk. There were tears of worry in her eyes. I understood her frustration. Over the years, I'd watched patients grow worse, all the while refusing the treatment that would make them better, whether it was a blood transfusion, a drug, or simply to quit smoking. But now my patient was someone I loved.

How did one treat failure to thrive in a vampire? Well, how did one treat it in a human? If Esme were a human patient, I would have set up some kind of force-feeding method already. Parenteral nutrition wouldn't work on a vampire; we had no bloodstream. But a nasogastric tube might, as the nasopharynx and esophagus of a vampire were much the same as a human's.

"Stay with her for a few minutes," I instructed Alice. "I'm going to get some supplies from my office."

She checked the future to see what I was planning, and nodded in solemn understanding. I left her perched on the back of the couch, keeping a watchful eye on Esme while I ran down to my office.

For reasons best left unknown, medical professionals have a compulsion to hoard medical supplies, and I am no exception. I found what I needed in the colored chest of drawers in my office, and filled a couple of the big 50ml syringes with moose blood. Supplies in hand, I went back upstairs. Alice hadn't moved an inch, and neither had Esme.

"You need my help?" she asked.

I nodded gravely. "You think you can?"

"It's going to help her."

"You can't …see what this is, can you?" I asked, already knowing the answer. If she'd known, she would say something.

She shook her head and said, "It's blurry, unresolved. I guess the future depends on us this time."

"A sober thought."

"Yeah. Hey, Esme?" Alice tapped her mother's arm. "Esme, you with us?"

"I need you to sit up," I instructed her, taking her more firmly by the shoulders. This seemed to rouse her from whatever stupor seemed to have taken her. She stirred and, with my and Alice's help, sat up. Alice sat on the back of the couch behind her and pulled her dull hair back from her face. Esme looked down and saw my medical tray, the tubes, the syringes, and grimaced.

"Are you going to …?" she started to ask.

"You need nutrients," I explained. "I'm going to put a tube down your esophagus into your stomach so that you won't have to taste the blood."

She sighed and didn't say anything. I hated the resigned, beaten look on her face more than anything. And I knew that feeding her would only treat a symptom.

I put on gloves, out of habit more than anything, and unwrapped the nasogastric tube, a long yellow silicone snake. I dabbed lubricant on the tip to make it go down easier. There was a numbing gel you could use, but I doubted it would work on vampires.

"It's not going to be comfortable," I continued. "You're going to feel like you're gagging. Try to swallow. I'll do it as gently as I can."

She nodded. "Okay."

I tried to feed the tip of the tube into her nasal cavity, but Esme leaned her head backwards, whimpering at the sensation.

"Alice, hold her head," I instructed. Sometimes you have to be cruel to be kind.

From her perch on the back of the sofa, Alice held Esme's head still as I slid the tube into the nasal cavity, past the nasopharynx, the pharynx, down the esophagus, and into the stomach. Esme coughed weakly a few times as it went down, her eyes shiny with tears, but didn't say anything. When I was done, I checked the placement and taped the tube to her pallid cheek. She reached up and touched it, feeling this invader with the tips of her fingers.

"Does it hurt?" I asked. "It shouldn't hurt if it's in properly."

Slowly, she shook her head. "No pain."

"I'm going to push some blood," I told her, picking up the first syringe I'd prepared. "Let me know if anything starts to hurt or feel wrong." I connected the syringe to the tube and pushed about a milliliter every five seconds. Alice sat next to Esme and cradled her mother's head against her shoulder while I finished the first syringe. I started on the second, watching carefully for signs of improvement. By the middle of the third syringe of blood, the purple spots under her eyes had faded just a little, and her waxy pallor was slowly lifting.

"How's it feel, Momma?" Alice asked.

"Better," Esme whispered. She rubbed at her forehead. "Now, if I could only ease this migraine…"

Alice cast me a worried glance as I disposed of the packaging and used syringes.

"She's had migraine-like symptoms for the past few days," I said. "I'm going to need to do more research to find out why, but we can try some of the usual human remedies in the mean time."

"Cold cloth, dark room, stuff like that? I can handle it if you want to go hit the books."

"Very well. I'll be in my office if you need me."

Three hours later, I had read every single word Beatrice Sutcliffe sent me, and I was no closer to diagnosing Esme. There were three known diseases that affected vampires, all mutant strains of candida, all very rare, and none of them matched her symptoms or the progression. So either this was something new—entirely possible, given the rate at which bacteria evolve—or it was the result of exposure to something toxic.

Something toxic. The thought triggered a memory, and an idea. Typing furiously, I penned another electronic missive, this one to a young man that I wouldn't exactly call a friend. He was human, unlike most of my acquaintances, and sometimes I found myself mourning that he only had another forty or fifty years left, while I had hundreds. But I knew that he wouldn't have it any other way.

Martin Hunter came from a long line of, for lack of a better word, vampire slayers. According to family lore, his ancestors had narrowly survived an encounter with the Voluturi, and been inspired to learn every weakness that the vampire species possesses, and how to exploit them. Their descendants had continued the tradition, and by the time Martin and his siblings came along, the Hunter clan had several rather high-profile kills under their belt. I'd known a few of their victims by reputation, and I could safely say that the world was better off without those particular vampires.

Martin himself was an expert in the various chemicals that vampires were susceptible to, and he designed chemical and biological weapons for his family to use on the hunt. We'd met once, years ago, when his sister brought him to my emergency department with acid burns on his hands and forearms from a "work accident." His sister had come perilously close to killing me, until she noticed the color of my eyes and allowed me to explain that my family was different. Martin had thanked me for my medical treatment, and my discretion, and since then he emailed sporadically, mainly because it irritated his family that he was friends with a vampire.

He wasn't exactly a scientist; his highest level of education was a GED. But he was the closest thing to a paranormal toxicologist that I knew, and right now he was probably my best hope.

To my relief, he got back to me less than an hour later. I clicked on the email.

 _Carlisle,_

 _Lovely to hear from you. Sorry about the missus. Well, a few thoughts:_

 _First of all, you're right; it's not a disease. If it's causing appetite loss, my money's on one of the neurotoxins. Almost all the neurotoxins that affect humans also affect vampires, but the effects aren't as dramatic, just dulled reflexes, fatigue, head pain, appetite loss, stupor, feeling lousy, and it takes a pretty large dose to get to that point._

 _So, the usual suspects—any snakebites lately? I doubt they can pierce your skin, though, and it would take about fifty snakebites to reach a toxic dose. Botulism, but you guys don't eat, so I can't imagine where you'd pick that up. The stuff produced by tetanus bacteria would do it, but again, you'd need a ton of it. Shellfish toxins, and the stuff produced by algae blooms—so maybe going swimming in red tide? Lead, mercury, and most heavy metals would do it too. My advice would be to try and figure out where she's been and where she might have been exposed. I asked sis and she says treatment is mostly to stop exposure and provide supportive care._

 _Oh, and sis also says to tell you hi._

 _Much love and formic acid,_

 _MH_

As hastily written as that email was, it had given me as much insight as Dr. Sutcliffe's and Anna Camp's work. And speaking of Anna…I slowly shut my laptop and stood up, remembering the note she'd scrawled at the bottom of her neurology paper, about targeting the hypothalamus to control appetite in newborns.

I flashed back to Esme as a newborn, her bloodred eyes, her lightning reflexes, her hair streaming out behind her as we ran through the woods, hunting for her first meal. The sound of the bear we pursued together. The smell of blood, fresh and sharp and enticing, from a duck hunter's scraped forearm.

Esme, standing over his body, blood dripping down her chin. It had happened so fast that she didn't even remember doing it. Her first blood had been human, and I'd never completely let go of the guilt. Neither had Esme.

* * *

Thank you all, for the reviews, follows, and favorites. I am humbled by the response that this little exercise in medical writing has gotten.

The next and final chapter will be the reveal, but I think some of you will be able to guess the answer.


	6. Chapter 6 Poison

"Alice?" I whispered, peeking into Esme's and my room. The lights were off, the curtains drawn, and Esme lay on the couch with a cold washcloth over her eyes. Alice stood by the doorway, expecting me.

"She's comfortable enough," my daughter reported. "Well, except for that damn tube."

"I'll take it out as soon as I can. I think I know what's wrong with your mother, but I'll need to ask her some questions to make sure. Do you mind giving us some privacy?"

"I'll be outside." She waltzed down the stairs and was gone in the blink of an eye.

I entered the room and shook Esme by the shoulder. "Are you feeling any better?"

"A little," she murmured, placing her hand over mine and sitting up. "Thank you for everything you've done for me."

"You're my wife," I said, "and you'd do the same for me. But I have to have a serious talk with you now. Alice is outdoors; she can't hear. I need you to tell me—were you trying to get rid of your thirst?"

"Whatever do you mean?" she asked, but the look on her face told me everything.

I sat down next to her, close but not touching. "Esme, why didn't you just tell me if you were having trouble? You didn't have to poison yourself."

She looked up at me for a second before she started to cry. Her shoulders shook and she buried her face in her arms, avoiding my eyes. I put my hand on her back and waited for it to pass.

"I was ashamed," she said finally, her voice still rough with tears. "I was—am—ashamed of my weakness. I love being immortal, Carlisle, and I love being with you, and I love our children, but I hate this bloodlust and how it makes me someone I'm not. It made me a murderer!"

"Esme, that wasn't your fault," I soothed. "We talked about it. You smelled blood at the exact moment you were least prepared to handle it. It was the perfect storm of bad luck."

"You would've been able to resist. You've never tasted human blood except to turn us. You even work in a hospital and it's never affected you. It always looks so easy."

I had to admit, it was easy for me, but I always attributed it to three hundred years of practice, plus my father's rather violent influence. I asked, "Why now? You told me you were hardly ever tempted."

She shook her head. "I thought so too. I thought I was old enough, and had abstained for long enough, that it wouldn't be a problem anymore. But then I was at the home and garden store getting lumber, and one of the men helping me cut his finger on the saw blade, and—" she broke off and rubbed her eyes. "It's the closest I've come in eighty years. I made up some excuse and ran out the back exit. I didn't stop until I got home. And then I couldn't bear the possibility that I might not be able to resist next time."

"What did you take?" I asked, after a brief silence. I'd asked this question to hundreds of people by now, drug users and patients who'd attempted suicide. I never thought I'd be asking one of my own.

"Lead," Esme said, in a small, flat voice. "The house is very old, and the original paint was lead-based. There were a few cans left in the basement that I never bothered to throw away. I saw them and I—I remembered something about one of the symptoms of lead poisoning being loss of appetite. I had no idea if it would have that effect on a vampire but I had to try something. And it worked, I suppose. I could probably walk right into your emergency room full of bleeding patients and not be tempted at all."

I didn't know what to say. I put my arm around Esme and hugged her to my chest. I hated that she'd gotten this desperate and felt she couldn't tell me. I hated that she'd done such harm to herself trying to protect other people. And I hated that I hadn't seen it until it was almost too late. It was the old cliché: a doctor too focused on his patients loses sight of those closest to him. Physician, heal thy family.

"Esme, my love, I'm so sorry," I murmured. But remorse didn't help anyone, and the doctor part of me had already begun formulating a treatment plan. "You're going to be okay, now that I know what this is. The first thing we'll do is see if the lead works its way out of your body on its own. If not, there's something called a chelating agent that will bind to the lead and render it harmless. And then I'll teach you some of the tricks I used to avoid temptation when I was younger. We can practice together."

"What sorts of tricks?"

"Focusing on other senses, like what you're seeing or hearing is a good one. There's also controlled exposure, so that you can become habituated to the smell of blood without putting anyone in danger."

"Is that how you're able to work as a doctor?"

I nodded. "I got my practice in the medical school cadaver lab. A dead man's blood is a good place to start, as the cells have begun to break down and the smell is not as strong. I worked my way up gradually. Even so, it was a great many years before I could watch an entire surgery from start to finish without becoming overwhelmed. It's a slow process, but I think you'll do just fine. I know you will."

I said a silent prayer to God that I was telling the truth, that Esme would have the strength to bear this cross. She was my light; I couldn't stand to lose her.

"Carlisle?" she asked, finally looking up at me.

"What is it?"

"How much longer do I have to have this tube in me? I must look ridiculous."

That broke the ice. I smiled and said, "When you can take blood by mouth, I'll remove it. And you could never look ridiculous, my dear."

The next few days were a relief. I gave Esme the rest of the moose blood, and she felt much better after that. I theorized that perhaps the blood was helping to push the lead out of her tissues, and immediately sent Alice into the woods for more. When she asked what was wrong with her mother, I told her that Esme had been exposed to some lead paint doing one of her building projects. The rest of the story was Esme's to tell or not as she wished.

After twenty-four hours and an entire mountain lion's worth of blood, Esme felt well enough to drink on her own. Once I was confident that she wasn't going to refuse to drink again, I removed the nasogastric tube, much to everyone's relief.

By the time Emmett, Rose, Edward, and Jasper came home, Esme was almost back to her usual self. She hugged everyone as they came in the front door, and admired the dress Rosalie had bought in Tacoma. When Emmett asked why there was blood in the fridge, I gave him the same sanitized version of events I'd given Alice, adding that Esme was too weak to hunt and probably would be for the next few days.

"No problem," he said, "and I can catch her anything she wants to drink, just say the word."

He made good on his promise, too, coming home one night with several containers of the grizzly blood that Esme had asked for. The others went out of their way to be nice to her as well. Edward played her favorite songs on the piano, and Jasper gave her a new set of drafting pencils. Alice, who had been learning some tailoring skills, started making her mother a new dress. Even Rosalie, who usually kept her distance, offered to do Esme's hair for her.

The afternoon before I was supposed to go in for my shift, I called Dr. Snow and asked him if he'd mind covering for me that night, as I wasn't feeling well. He agreed readily, since I covered for him at least once a month when an important sports game fell on a day he was scheduled.

"You never call off work," Esme said, standing in the doorway of my office.

I stood up. "It's good to call in sick at least once a year, for appearance's sake. How are you doing?"

"Better. Much better, actually. You and the kids take good care of me." She reached over and laced her fingers in mine.

"They're hovering a bit, though, aren't they?" I asked, as Edward began another rendition of Pachelbel's Canon.

"Maybe a bit," she conceded, sensing I had something planned.

"How would you like to take a trip tonight, just the two of us? We can go anywhere you want."

She smiled and squeezed my hand. "Well, it's perfect swimming weather. And I recall a fever dream of you and me lying at the bottom of the ocean, watching the sunlight on the water above us."

I kissed her forehead. "Absolutely. I know the perfect place."

After telling the kids where we were going and when we would be back, we changed into something more appropriate for the beach and headed north, to a beach near the tip of the Olympic Peninsula. Medicine and lead poisoning were far from my mind as I parked the car and we stepped out onto the sand barefoot. Our bare skin glowed in the sunlight.

"Come on," Esme called, taking my hand as she ran past. I broke into a run as well, and we sprinted across the sand until the sand gave way to the gray rock of sea cliffs. Salty air blew through our hair as we stumbled to a halt at the very edge of the cliff.

"That's a nice little cove," I commented, staring down at the sandy inlet at the bottom of the cliffs. "It's probably covered at high tide."

Esme smiled, and before I could say anything, she turned around and did a backflip off the edge of the cliff. Tucking her knees, she did a few somersaults on her way down, then straightened up in time to stick the landing. Impressed, I jumped after her, felt the air rush around me, the stomach-turning joy of freefall. I landed next to her, the force of the impact driving me knee-deep into the wet sand.

We splashed in the shallows for a while, and Esme tucked a few interesting shells into her pockets for later. When the tide started coming in, we found a small cave in the side of the cliff and waited. Slowly, the water rose to meet us. We laughed in excitement as the waves began sloshing at us, soaking us from head to toe. The water seemed to rise even faster, until we were completely submerged. I filled my lungs with water so that I wouldn't float to the top. A tower of bubbles rose next to me as Esme did the same.

Brightly colored fish swam up to us and nibbled at our fingers, then swam away in a hurry, sensing we didn't quite belong. Crabs scuttle along the sandy ocean floor, and mollusks opened their shells to eat. Sunlight danced across the surface of the water above us as we watched, cocooned by the ocean, with our fingers interlaced.

~ fin

* * *

 **Author's note** : Thank you so much to everyone who read, reviewed, and followed. This piece started as idle musings about how Dr. Carlisle would handle certain patients of mine. I never imagined that it would be this well-received. So thank you, everyone.


End file.
